How the MetLife Dental Copay Plan Works

How It Works

The MetLife Dental Copay Plan is a dental plan in which you make a copay based on a fee schedule, called the Procedure Charge Schedule. The Procedure Charge Schedule is based on the ZIP code where your dentist’s office is located. Each time you need care, you can visit any licensed dentist you choose. However, if you visit a preferred provider, you save money since providers in the network charge negotiated rates. If you visit an out-of-network provider you must meet an annual deductible and you pay a higher copay.

For a listing of network providers, visit the MetLife website at: www.metlife.com/mybenefits. Provider information can also be obtained on our website at.http://hr.uchicago.edu. A provider list may be obtained, without charge, through the website or by contacting MetLife directly.

The table below shows the deductible, and approximate Copay percentage that you’ll be asked to pay at the time that dental services are rendered. For a current list, contact MetLife directly or visit their website at www.metlife.com/mybenefits or visit our web site at http://hr.uchicago.edu.

MetLife Dental Copay Plan
	In-network	Out-of-network
Choice of Dentist	Network providers only	Any licensed provider
Deductible	None	$75 per covered individual (waived for Orthodontia) $225 per family (waived for orthodontia)
Annual Maximum Benefit	$5,000 per person	$1,000 per person
Preventive Care	You make a copayment (approximately 10% of the cost), then Plan pays the remainder (up to the annual maximum) – up to 2 visits per year separated by 6 months	You pay 30%; Plan pays 70% (up to the annual maximum); you pay any amount over the reasonable and customary charges – up to two visits per year separated by 6 months
Basic Care (e.g. fillings)	You make a copayment (approximately 30% of the cost), then Plan pays the remainder (up to the annual maximum)	You pay 60%; Plan pays 40% (up to the annual maximum); you pay any amount over the reasonable and customary charges
Major Care (e.g. crowns)	You make a copayment (approximately 60% of the cost), then Plan pays the remainder (up to the annual maximum) after deductible	You pay 70%; Plan pays 30% (up to the annual maximum); you pay any amount over the reasonable and customary charges
Orthodontia (e.g. braces)	You pay 60%; Plan pays 40% (up to the lifetime maximum of $1,500)	You pay 60%; Plan pays 40% (up to the lifetime maximum of $500); you pay any amount over the reasonable and customary charges
Claim forms	None	You file your own claims
Negotiated fees	Yes	No

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.